Matthew Cooperberg is Associate Professor of Urology and Epidemiology & Biostatistics at the UCSF Helen Diller Family Comprehensive Cancer Center. He is a urologic oncologist specialising in prostate cancer management. Matt is a highly published academic surgeon, having written/co-authored 130 peer-reviewed journal articles and 12 book chapters. He is Associate Editor for European Urology and sits on multiple other editorial boards.

Declan Murphy is Uro-Oncologist and Associate Professor of Surgery at the University of Melbourne, Peter MacCallum Cancer Centre. He is an Associate Editor at the BJUI and holds other senior editorial positions at European Urology and Nature Reviews Urology.

Declan, what was the rationale behind writing the Melbourne PSA Consensus Statement?

“The Melbourne Statement was a response to the very confused landscape we found ourselves in after the release of the USPSTF Recommendation last year and to a lesser extent, the AUA PSA Guideline a few months ago. While the USPSTF recommendation was frankly ridiculous and unworkable (PSA is not going to go away), the AUA Guideline did have some merit. However we felt that it did not adequately address some areas, e.g. how should we approach the average man in his 40’s who does not want to die of prostate cancer? Knowing that we would have a gathering of highly respected experts in prostate cancer in Melbourne in August 2013 we decided to release a simple document, which would provide straightforward guidance for GPs and others.”

Matt, has the statement been well received by Urologists, Patients and GPs/Family Doctors in the US?

“I was quite impressed with the press coverage in Australia and even in the U.S. when it was presented at the PCWC conference in Melbourne. We’ll see how much more discussion it generates when the final document is published in British Journal of Urology International. Ultimately, though, at least in the U.S., urologists’ recommendations don’t carry much weight with the primary care providers who are really making PSA testing decisions. They give far more credence to the USPSTF, unfortunately. Likewise in Australia, the RCGP Red Book is the bible for many GPs and it is very anti-PSA testing. Nevertheless we have had much positive feedback from GPs already.”

Matt, the USPSTF position statement essentially came out against PSA testing. Has this had a measurable impact on PSA testing in the US?

“This is hard to say so far. In 2009 the USPSTF came out against testing among older men, and multiple papers have shown that the recommendation had virtually no impact on PSA testing rates in the older population. However, this time it seems to be different. While there are no published data yet, multiple anecdotes seem to suggest that many primary care providers are simply abandoning PSA testing—equally for younger men in good health as for older ones with significant comorbidity. It is very much a case of throwing the baby out with the bath water.”

Matt, if the reductions in metastasis and prostate cancer mortality with PSA testing are so large, why does the consensus not support a population-wide screening programme?

“That term (population-wide screening) tends to imply reflexive PSA testing without any a priori discussion with the individual man. Enough controversy and confusion exists regarding both screening and prostate cancer treatment—and overtreatment is still enough of a problem in the U.S. and elsewhere—that we should not be screening men without warning them of the possible outcomes of testing. The relative cancer-specific mortality reductions are large, but the absolute reductions are not with 10-15 year follow-up, thus leading to calculations of relatively high numbers needed to screen and diagnose to prevent one cancer death. Though these numbers fall substantially with longer follow-up (a horizon of 30 years or more is entirely appropriate for a 50 year old man facing a screening decision), most men with prostate cancer die of cardiac disease, just like those without prostate cancer.”

Declan, are there any improvements or changes to the document planned?

“The document is set to evolve. One of the benefits of publishing it as a blog at bjui.org was to get it into circulation very quickly and also to allow others to comment. Within 72 hours the Melbourne Statement had become the most-read and most-commented blog at BJUI. The print version will appear in the BJUI in coming months.”

Matt, what is the future for PSA testing in your view?

“It’s very hard to say. I think many of us know the way PSA screening should evolve: men should be offered testing at a relatively young age—with the express understanding that testing is intended to detect high-risk prostate cancer, and that if a low-risk tumour is identified, it does not need immediate treatment. Those with low baseline PSAs can be re-screened less frequently than they are now. Evolving biomarkers will help determine who needs a biopsy and who needs treatment, but PSA is not going anywhere as a first screen. From what I understand, most national policies are evolving toward some variation on a “smarter screening” approach. Unfortunately, in the U.S. it will likely require a legislative remedy to force the USPSTF to accept actual expert opinion before the policy is corrected. There is a bill working its way through Congress to do just this, but it is not a quick process.

"In the meantime, the best we as urologists can do is to implement smarter screening in practice, to strive to reduce overtreatment and to improve quality of treatment when it is needed, to continue to advocate for USPSTF reform, and to reach out to local groups of primary care providers to educate them that the truth about PSA—which, as is usually the case in medicine, is neither black nor white. Only through understanding the truth in the shades of grey can we at once maximise the benefits of screening and minimize its harms.”